Management of clinical chorioamnionitis: an evidence-based approach.
Study Goal
The researchers aimed to evaluate the potential of N-acetylcysteine as an antioxidant and anti-inflammatory agent to reduce neonatal morbidity and mortality in patients with clinical chorioamnionitis.
Results Summary
The study suggests that antenatal administration of N-acetylcysteine may reduce neonatal morbidity and mortality, but well-powered randomized controlled trials are needed to confirm these effects.
Population
Pregnant individuals with clinical chorioamnionitis between 24 0/7 and 33 6/7 weeks of gestation, and possibly between 23 0/7 and 23 6/7 weeks.
Effective Dosage
Not specified
Duration
Not specified
Interactions
None mentioned
| Intervention | Direction | Endpoint | Population | Dosage | Impact | Claim # |
|---|---|---|---|---|---|---|
ampicillin combined with gentamicin | neutral | treatment of clinical chorioamnionitis | patients with clinical chorioamnionitis | - | is the first-line antimicrobial regimen | #1 |
clindamycin | neutral | - | patients at the time of umbilical cord clamping during cesarean delivery | - | should be received | #2 |
additional antibiotic therapy | no change | - | patients after vaginal or cesarean delivery | - | does not appear to be necessary | #3 |
antipyretic agents, mainly acetaminophen | no change | - | patients with clinical chorioamnionitis | - | can be received even though there is no clear evidence of their benefits | #4 |
antenatal corticosteroids for fetal lung maturation | increase | fetal lung maturation | patients with clinical chorioamnionitis between 24 0/7 and 33 6/7 weeks of gestation, and possibly between 23 0/7 and 23 6/7 weeks of gestation | - | has an overall beneficial effect on the infant | #5 |
magnesium sulfate for fetal neuroprotection | increase | fetal neuroprotection | patients with clinical chorioamnionitis between 24 0/7 and 33 6/7 weeks of gestation, and possibly between 23 0/7 and 23 6/7 weeks of gestation | - | has an overall beneficial effect on the infant | #6 |
vaginal delivery | neutral | - | patients with clinical chorioamnionitis | - | is the safer option | #7 |
time interval between the diagnosis of clinical chorioamnionitis and delivery | no change | most adverse maternal and neonatal outcomes | patients with clinical chorioamnionitis | - | is not related to | #8 |
oxytocin | increase | uterine activity | patients with clinical chorioamnionitis | higher dose | may require a higher dose to achieve adequate uterine activity or greater uterine activity to effect a given change in cervical dilation | #9 |
continuous electronic fetal heart rate monitoring | no change | - | patients with clinical chorioamnionitis | - | benefit is unclear | #10 |
antibiotic regimen including ceftriaxone, clarithromycin, and metronidazole | increase | coverage against microorganisms | patients with clinical chorioamnionitis | - | provides coverage against the most commonly identified microorganisms | #11 |
vaginal cleansing with antiseptic solutions before cesarean delivery | decrease | endometritis and, possibly, postoperative wound infection | patients before cesarean delivery | - | aim of decreasing the risk | #12 |
antenatal administration of N-acetylcysteine | decrease | neonatal morbidity and mortality | patients with clinical chorioamnionitis | - | to reduce | #13 |
This review aimed to examine the existing evidence about interventions proposed for the treatment of clinical chorioamnionitis, with the goal of developing an evidence-based contemporary approach for the management of this condition. Most trials that assessed the use of antibiotics in clinical chorioamnionitis included patients with a gestational age of ≥34 weeks and in labor. The first-line antimicrobial regimen for the treatment of clinical chorioamnionitis is ampicillin combined with gentamicin, which should be initiated during the intrapartum period. In the event of a cesarean delivery, patients should receive clindamycin at the time of umbilical cord clamping. The administration of additional antibiotic therapy does not appear to be necessary after vaginal or cesarean delivery. However, if postdelivery antibiotics are prescribed, there is support for the administration of an additional dose. Patients can receive antipyretic agents, mainly acetaminophen, even though there is no clear evidence of their benefits. Current evidence suggests that the administration of antenatal corticosteroids for fetal lung maturation and of magnesium sulfate for fetal neuroprotection to patients with clinical chorioamnionitis between 24 0/7 and 33 6/7 weeks of gestation, and possibly between 23 0/7 and 23 6/7 weeks of gestation, has an overall beneficial effect on the infant. However, delivery should not be delayed to complete the full course of corticosteroids and magnesium sulfate. Once the diagnosis of clinical chorioamnionitis has been established, delivery should be considered, regardless of the gestational age. Vaginal delivery is the safer option and cesarean delivery should be reserved for standard obstetrical indications. The time interval between the diagnosis of clinical chorioamnionitis and delivery is not related to most adverse maternal and neonatal outcomes. Patients may require a higher dose of oxytocin to achieve adequate uterine activity or greater uterine activity to effect a given change in cervical dilation. The benefit of using continuous electronic fetal heart rate monitoring in these patients is unclear. We identified the following promising interventions for the management of clinical chorioamnionitis: (1) an antibiotic regimen including ceftriaxone, clarithromycin, and metronidazole that provides coverage against the most commonly identified microorganisms in patients with clinical chorioamnionitis; (2) vaginal cleansing with antiseptic solutions before cesarean delivery with the aim of decreasing the risk of endometritis and, possibly, postoperative wound infection; and (3) antenatal administration of N-acetylcysteine, an antioxidant and antiinflammatory agent, to reduce neonatal morbidity and mortality. Well-powered randomized controlled trials are needed to assess these interventions in patients with clinical chorioamnionitis.